COMMENTARY

What You Don't Know About Beta-Blockers and Patients on Hemodialysis

Tejas P. Desai, MD

Disclosures

March 18, 2021

There are a lot of beta-blockers out there, each with its own level of beta-1 or -2 selectivity. As a nephrologist, I don't usually think about beta-blockers as the first-line agent for managing hypertension in my patients with end-stage renal disease or chronic kidney disease. I use whatever beta-blocker I can get my hands on. But for my in-center hemodialysis patients, I generally choose a specific agent based on its dialyzability. I often refer to a study by Tieu and colleagues that assessed the dialyzability of the more "modern" beta-blockers.

On the basis of their analysis, my go-to beta-blocker for dialysis patients was carvedilol. It has the least dialyzability and thus, I figured, would offer the best cardioprotection and antihypertensive effects for my patients.

Then came the 2021 study by Wu and colleagues, who compared carvedilol against bisoprolol. They prospectively studied more than 20,000 patients to determine how carvedilol or bisoprolol affected death (the primary outcome) and major adverse cardiac events (MACE) which included the big three: heart attack, heart failure, and stroke. Despite being more dialyzable, bisoprolol reduced mortality by 35% and reduced all three MACE components by 17%.

That is amazing! I never thought a medication whose dialyzability was on the high end would protect hemodialysis patients better than one with a really low clearance (108 mL/min vs carvedilol's clearance of 17.70 mL/min). But apparently this isn't a new finding.

Figure. Download PDF here

In 2020, the same investigators compared highly dialyzable beta-blockers (atenolol, acebutolol, metoprolol, and bisoprolol) vs less dialyzable ones (betaxolol, propranolol, and carvedilol). In that study, the bisoprolol group had a lower risk for death and MACE than the carvedilol group. And if you go back even further, a nice retrospective review that I missed in 2015 showed lower death in the bisoprolol group than the metoprolol group!

These results prompted me to re-evaluate the beta-blockers I am using for my in-center hemodialysis patients. Luckily, I work at an institution that has bisoprolol on formulary, so making the change has been relatively easy. To solidify my knowledge, I created an infographic and published it on Twitter. Within days, people were admitting that they, too, were unaware of these findings and the benefits of using bisoprolol over the less dialyzable carvedilol.

The moral for me is that the dialyzability of a beta-blocker is not as important as its cardioselectivity. Bisoprolol has better beta-1 affinity, and maybe that gives it the ultimate edge over any less dialyzable agent. But perhaps in a larger sense, we need to overcome our own biases and look for data to guide our decision-making. I naturally thought that "less dialyzable" had to be better. It took three trials over the course of 6 years for me to see things differently.

Tejas Desai is a practicing nephrologist in Charlotte, North Carolina. His academic interests include the use of social media for physician, student, and patient education. He is the founder of NOD Analytics, a free social media analytics group that serves the medical education community. He has two wonderful children and enjoys spending time with them and his wife.

Follow Tejas P. Desai, MD, on Twitter: @nephondemand

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